Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
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Tuesday, January 15, 2008

When I see this as a chief complaint in a progress note I know what I'm going to read next: a diagnosis of bipolar disorder, not otherwise specified, and an order for the mood stabilizer du jour. What I will not (usually) see is a description of what mood states the patient is "swinging" between, the duration of those mood states or a list of associated symptoms. This isn't specific to correctional work in that I've also seen documentation like this in discharge summaries I've received from hospitals.

I'm familiar with the various "flavors" or subtypes of bipolar disorder that have been hypothesized, but the guys I treat don't fall into a clearcut diagnostic category (unless you count personality disorders) and sometimes there are cases that really push the boundaries between an Axis I and an Axis II problem. I see this a lot when I'm dealing with inmates with a history of institutional violence.

People who do research on violence struggle over how to define or characterize violent acts. You'll see references to predatory violence versus instrumental violence versus opportunistic violence versus impulsive aggression. The nuances elude me, other than to say that the one consistent thing seems to be the degree of planning (or lack thereof) involved in the act.

Before deciding to throw meds at the problem, I'll usually do an assessment to clarify whether or not violence really is an issue. You'd be surprised the number of guys who self-identify temper as an issue, but when you take their histories they've actually held it together quite well. Someone who only has one ticket (infraction) for fighting in a year of incarceration really can't be considered to have too much of a problem with violence. In cases like that I'll ask more questions to figure out exactly why the patient thinks it's a problem; more often than not, they're troubled by the fact that they merely have violent thoughts. In that case the inmate has unrealistic expectations of what a medication can do for their problem.

Other questions I ask are:

* who are you fighting with, inmates or officers or both?The choice or level of discrimination reflects the degree of control over the violence.

* have you gotten into fights that you haven't had tickets for?If the answer is yes, this usually means that the patient and his/her opponent plans the fight to avoid detection by custody, another situation where medication is unlikely to be of benefit.

* do you fight when you're sober and clean?By far the most common precipitant for violence is substance abuse, either in the facility or in free society.

* do you have a bad temper even when you're not depressed?Clinical depression can decrease frustration tolerance for prisoners. This is often the factor that causes them to seek treatment when they wouldn't even think of seeing a shrink on the outside. Treating the underlying depression fixes the temper problem.

* tell me about some of the situations you've gotten mad in recentlyOften there's a good reason for it. Medication is unlikely to help you keep from getting mad when you've got people cursing at you or threatening you. Normal anger exists for a reason and medication will not keep someone from ever getting angry over things that would anger anyone.

So once I've done all this I'll decide whether or not the violence issue is one that might benefit from medication. I'll make it clear in my note that violence is the target symptom and I won't try to stretch a diagnosis to justify a treatment plan.

I think all classes of pharmacologic agents have been used to treat violence at one time or another, but most recently mood stabilizers have shown the most utility for aggression associated with personality disorders. Lithium has been used for this since the original studies in the 1970's, when it was found to cut the violent infraction rate in prisoners by about half. (Interestingly, some of this subjects also discontinued the medication on their own because they didn't "feel" it working, even when it was.) Valproic acid, carbamazepine and now the atypical antipsychotics have all been used for this. SSRI's can have an interesting pro-apathy (if that's a word) effect in some people, giving them the ability to "shrug off" experiences that they normally would have gotten upset about. Regardless, the goal is to lengthen the patient's fuse and give them time to think before they act.

As one patient of mine put it: "The medication doesn't lengthen my fuse. It gives me a fuse."

8
comments:

Thanks for this, clink. I always like your articles, because they aren't easy for me. That tells me that I really am learning something about a world I know nothing about.

Some clarification for this free-society nitwit?

"...more often than not, they're troubled by the fact that they merely have violent thoughts. In that case the inmate has unrealistic expectations of what a medication can do for their problem."

"SSRI's can have an interesting pro-apathy (if that's a word) effect in some people, giving them the ability to "shrug off" experiences that they normally would have gotten upset about."

To me, those two statements appear to contradict one another.

I don't know if I have a distorted view of things, but thoughts are pretty important to me. My beloved has spent long stretches not daring to leave his apartment, even to do groceries, because he was afraid of getting into a fight (and getting killed). During these periods he would have many violent fantasies, more usually involving things than people. An inventory of acts of aggression would have revealed little or nothing, but his thoughts were both a big problem for him and relieved by a mood stabiliser. I worried about him back then and feel as though he's being appropriately treated now.

I guess the difference between my beloved and your clientele is that your folks don't have the option of avoiding provocative situations, so someone who has been able to refrain from violence is someone who by virtue of that fact has his shit together? I still feel concerned about the price that someone may have to pay to stop themselves from giving in. My beloved paid a high price for the safety most of the rest of us take for granted. Do you distinguish between people whose thoughts stretch them to the limit and those who just feel guilty for not being Buddha?

"My mood is swinging" means "I'm irritable." That's what it means. It's taken me 15 years to get there, and I ask the patient to clarify this. What do you mean by swinging? I then ask for an example of what happened, and I get a story of irritability, or low frustration tolerance, or...irritability. If someone HAS bipolar illness, they may say that they were depressed earlier and now they're a bit elated, but...oh, that never really happens. "My mood is swinging," means "I'm irritable." and I re-phrase it as such for them.

Irritability is a symptom of a number of conditions, including bipolar disorder, depression, anxiety, a poor night's sleep, exposure to idiots or idiotic circumstances, PMS, and low frustration tolerance as a personal trait or momentary response to feeling overwhelmed. It is also seen in a wide variety of personality disorders.Finally, it is part of the general human condition, even among the mentally healthiest of people living among the bestest of circumstances.

. . . in older adults, lability of mood and increased hositility can be due to dementia.

We know that neurodegenrative processes like Alzheimer's hit the limbic system before you have significant parietal lobe and cortical atrophic change causing the memory problems. Thus, anyone with clinical symptoms will have limbic system damage.

Misperception, misinterpretation and abberant ideation from congitive impairement can all generate behavioural and psychological symptoms of dementia (BPSD) that presents exactly as you describe as lability of mood and aggression.

"We know that neurodegenrative processes like Alzheimer's hit the limbic system before you have significant parietal lobe and cortical atrophic change causing the memory problems. Thus, anyone with clinical symptoms will have limbic system damage."

Is that the ICD previously known as "Grumpy old bastard" diagnosis? :)

Thanks for the post and comment, respectively. I have been very, very angry lately and really did not understand why. I also am getting road rage and have started honking at cars that cut me off when I used to just shrug it off and keep singing my Fleetwood Mac at the top of my lungs.

I can't even describe my rage. Ugh! Thanks.

Thanks for putting up with me. This is so interesting to me.

I think I may be learning a bit.

Unfortunately, anger doesn't endear you to the people you need/want help from.

People like "nice" people who are "easy" to get along with. I try my best to be polite and nice. Right now I have a blank card on my desk that I am going to fill with a greeting to a former co-worker who had a stroke (retired).

Dinah said, "If your irritability is associated with a tendency to get into altercations, treatment is a good thing, and avoid provocative situations while you sort things out is a wise idea."

Let's say someone's irritability got them put into hospital twice, seven to ten years ago. Since that time, they have been careful to not leave the house when irritable. Because these irritable periods can last for weeks, sometimes that means they go hungry. It certainly puts a dent in their ability to support themselves.

My understanding of what you and clink are saying is, "Since this person has a good way of managing their irritable thoughts, as evidenced by the fact that they don't get into fights, a) they don't have a problem beyond thoughts and b) thoughts won't be helped by meds anyway and they are being unrealistic to think that a psychiatrist can help them."

Since I don't think that is what you actually think - and if it is, careful how you express it because telling a desperate person that you can't help them / they don't have a problem until they commit an act is essentially saying "Try to kill someone and then get back to me, I'll see what I can do for you then" - what I'm asking for is clarification on the "only thoughts" bit.

TA: I think you touched on the key difference when you mentioned the fact that my patients don't have the option of avoiding provocative situations. Many of my patients, even those who don't complain of irritability, will stay in their cells during recreation time to avoid confrontation with other inmates so restriction of activity isn't necessarily a measure of how bothersome the thoughts are.

The Shrink: Good point about dementia. I thought about mentioning that but my patients tend to be rather young for it. Except for the HIV folks, of course.

Lily: To be a shrink you have to able to work with irritable people. I wouldn't worry about it.